| ADDRESS: 805 DEVELOPMENT DR, KINGSTON, ON K7M 4W6 TEL: 613-389-8660 EMAIL: reception@davidgouettdentistry.com
# NEW PATIENT FORM Your co-operation in completing this questionnaire is essential to providing you with the highest standard of dental care. All information is strictly confidential.
1. REGISTRATION INFORMATION
THE PATIENT IS AN | [Adult / Child / Adult under guardianship]
NAME OF GUARDIAN | [Guardian Name]
FIRST NAME | [First Name]
LAST NAME | [Last Name]
TITLE | [Dr. / Mr. / Mrs. / Ms. / Miss.]
PREFERS TO BE CALLED | [Preferred Name]
EMPLOYER | [Employer Name]
ADDRESS: STREET | [Street Address]
ADDRESS 2: STREET | [Apt/Suite]
CITY AND PROV/STATE | [City], [Province]
ZIP/POSTAL CODE | [Postal Code]
REASON FOR TODAY’S VISIT? | [Examination / Emergency / Other] | [Other Details]
IS THERE A DENTAL PROBLEM YOU WOULD LIKE TREATED IMMEDIATELY? | [Response]
PREFERRED APPT. TIME? | [Preferred Time]
HOME PHONE | [Home Phone]
CELL PHONE | [Cell Phone]
PAGER NO. | [Pager No.]
BUS. PHONE | [Bus. Phone] Ext: [Ext]
E-MAIL ADDRESS | [Email Address]
MAY WE CALL YOU AT WORK? | [Yes / No]
PREFERS TO BE CALLED | [Location Selection]
OCCUPATION | [Occupation]
DATE OF BIRTH (M/D/Y) | [MM/DD/YYYY]
AGE | [Age]
GENDER AND PRONOUNS | [Gender/Pronouns]
MARITAL STATUS | [Marital Status]
NAME OF SPOUSE | [Spouse Name]
ARE OTHER FAMILY MEMBERS PATIENTS AT OUR OFFICE? | [Yes / No] | Names: [Names]
WHOM MAY WE THANK FOR REFERRING YOU? | [Referral Name]
FAMILY PHYSICIAN | [Physician Name]
PHONE | [Physician Phone]
MEDICAL SPECIALIST (IF PRESENTLY UNDER CARE) | [Specialist Name]
PHONE | [Specialist Phone]
IN CASE OF EMERGENCY, PLEASE CONTACT | [Emergency Contact Name]
PHONE | [Emergency Contact Phone]
2. FINANCIAL & CREDIT INFORMATION
PERSON RESPONSIBLE FOR ACCOUNT: | [Self / Spouse / Other]
NAME: LAST, FIRST | [Responsible Name]
HOME PHONE | [Home Phone]
DRIVER'S LIC. NO. | [DL#]
HEALTH CARD # | [Health Card #]
CREDIT CARD NO. | [Credit Card No.]
EXPIRY DATE | [MM/YY]
PRIMARY DENTAL INSURANCE
SUBSCRIBER'S NAME | [Subscriber Name]
D.O.B. | [MM/DD/YYYY]
INS. YR. END | [Date]
EMP./GRP. POLICY HOLDER | [Policy Holder]
INS. CO. | [Insurance Co.]
TEL. | [Insurance Phone]
GRP./IND. POLICY NO. | [Policy No.]
CERT. NO. | [Cert No.]
SECONDARY DENTAL INSURANCE
SUBSCRIBER'S NAME | [Subscriber Name]
D.O.B. | [MM/DD/YYYY]
INS. YR. END | [Date]
EMP./GRP. POLICY HOLDER | [Policy Holder]
INS. CO. | [Insurance Co.]
TEL. | [Insurance Phone]
GRP./IND. POLICY NO. | [Policy No.]
CERT. NO. | [Cert No.]
3. MEDICAL HISTORY QUESTIONS
1. Are you being treated for any medical condition at the present or have you been treated within the last year? RESPONSE: [Yes / No]
2. Has there been any change in your general health in the past year? RESPONSE: [Yes / No]
3. When was your last medical checkup? RESPONSE: [Patient Input]
4. Do you have any conditions that could affect your immune system? (e.g. Leukemia, HIV +/- tested, Lupus) RESPONSE: [Yes / No]
5. Are you undergoing any therapies that could affect your immune system? (e.g. Radiotherapy or Chemotherapy) RESPONSE: [Yes / No]
6. Are you currently taking any steroids or cortisone? RESPONSE: [Yes / No]
7. Do your ankles, feet or hands swell? RESPONSE: [Yes / No]
8. Are you allergic to any medications? RESPONSE: [Yes / No] | IF YES, PLEASE LIST: [Details]
9. Are you allergic to any of the following? (Latex, Metal, Rubber, None of the above, Not Sure) RESPONSE: [Selections]
10. Are you allergic to any foods? RESPONSE: [Yes / No] | IF YES, PLEASE LIST: [Details]
11. Do you have any other allergies that we should be aware of? RESPONSE: [Yes / No] | IF YES, PLEASE LIST: [Details]
12. Have you ever had any peculiar or adverse reactions to any medicines or injections? RESPONSE: [Yes / No] | IF YES, PLEASE LIST: [Details]
13. Are you taking or have you ever taken osteoporosis medications? (e.g. Fosamax, Actonel) RESPONSE: [I am currently taking / I was previously taking but am no longer / No] IF CURRENTLY OR PREVIOUSLY TAKING, PLEASE SPECIFY WHICH MEDICATION: [Medication Details]
14. Are you currently taking any prescription medications? RESPONSE: [Yes / No] | IF YES, PLEASE LIST: [Details]
15. Do you take any recreational drugs on a regular basis? RESPONSE: [Yes / No] | IF YES, PLEASE LIST: [Details]
16. Are you taking any herbal supplements of any kind? RESPONSE: [Yes / No] | IF YES, PLEASE LIST: [Details]
17. Do you have diabetes? RESPONSE: [I have Type 1 Diabetes / I have Type 2 Diabetes / No]
18. Do you have or have you ever had any of the following?
[List of selected conditions from: Arthritis/Rheumatism, Asthma, Cancer, Chest Pain/Angina, Crohn's Disease, Drug/Alcohol Dependency, Fainting or Dizzy Spells, Glaucoma, Hay Fever, Head/Neck Injuries, Heart Attack, Hepatitis A, Hepatitis B, Hepatitis C, Herpes - Oral/HSV-1, Hyperglycemia, Hypoglycemia, Jaundice, Kidney Disease, Liver Disease, Lung Disease/Emphysema, Malignant Hyperthermia, Mitral Valve Prolapse, Pacemaker, Psychiatric/Mental Disorders, Rheumatic/Scarlet Fever, Seizures (Epilepsy), Shortness of Breath, Sickle Cell Disease, Sinus Trouble, Stomach Ulcers, Hay Stroke, Thyroid Disease, Tuberculosis] SELECTED CONDITIONS:
• [Selected Condition 1] • [Selected Condition 2] • [Selected Condition 3] [Patient's Selected Conditions List]
19. Do you have or have you had any conditions or diseases not previously listed that we should be aware of? RESPONSE: [Yes / No] | IF YES, PLEASE LIST: [Details]
20. Are there any diseases or medical problems that run in your family? RESPONSE: [Cancer, Heart Disease, Diabetes, Malignant Hyperthermia, Other] | [Other Details]
21. Do you have a bleeding problem or bleeding disorder? RESPONSE: [Yes / No]
22. Do you have or have you ever had a replacement or repair of a heart valve or stent? RESPONSE: [Yes / No]
23. Do you have or have you ever had an infection of the heart? (e.g. Infective Endocarditis) RESPONSE: [Yes / No]
24. Have you had a transplant (heart, lungs, organs)? RESPONSE: [Yes / No]
25. Do you have a heart condition from birth? (e.g. congenital heart disease/lesions) RESPONSE: [Yes / No]
26. Do you have or have you ever had any heart or blood pressure problems? RESPONSE: [Yes / No]
27. Do you have a prosthetic or artificial joint? RESPONSE: [Yes / No]
28. Have you ever been hospitalized for any illnesses or operations? RESPONSE: [Yes / No]
29. Have you ever had any injury or surgery to your face or jaws? RESPONSE: [Yes / No]
30. Do you smoke or chew tobacco products? RESPONSE: [Yes / No]
31. Are you nervous during dental treatment? RESPONSE: [Yes / No]
32. Is there anything else about your health that we should be made aware of? RESPONSE: [Yes / No] | IF YES, PLEASE PROVIDE VERY BRIEF DETAILS: [Details]
33. Do you wish to speak to the doctor privately about any problem or medical condition? RESPONSE: [Yes / No]
34. Has the child patient recently had any of the following? RESPONSE: [Chicken Pox, Measles, Mumps, Chest Strep Throat, Tonsillitis, None/None Applicable]
35. Are there any immunizations that the child is not up to date with? RESPONSE: [Yes / No]
36. Are you breastfeeding? RESPONSE: [Yes / No]
37. Are you pregnant? RESPONSE: [Yes / No/Not applicable]
TO THE BEST OF MY KNOWLEDGE, ALL OF THE PRECEDING ANSWERS ARE TRUE AND CORRECT. IF I EVER HAVE ANY CHANGE IN MY HEALTH, OR IF MY MEDICATION CHANGES, I WILL INFORM THE DOCTOR AT THE NEXT APPOINTMENT WITHOUT FAIL.
DIGITALLY ENDORSED BY PATIENT [Patient Signature Placeholder] | DATE SUBMITTED [MM/DD/YYYY]
© 2026 David Gouett Dentistry. This record is protected under PIPEDA and PHIPA legislation. Unauthorized disclosure of this clinical information is strictly prohibited.